10-7078 Authorization And Invoice For Medical And Hospital Servi

OMB Number: 2900-0080
Estimated Burden: 2 minutes
Expiration Date: 11/30/2007

NOTE: Instructions are written for a multi-part form. Print additional copies as necessary.

AUTHORIZATION AND INVOICE FOR MEDICAL AND
HOSPITAL SERVICES
This information is collected under the authority of Title 38 1703, 1725 and 1728. In accordance with section 3507 of the Paperwork Reduction Act
of 1995, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We
anticipate that the time expended by all individuals who must complete this invoice will average 2 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the form. The purpose of this form is to authorize medical treatment and provide a means to bill for
this service although private providers may also use local billing forms or UB (Uniform Billing) Forms 92. Submission of this form is voluntary and
failure to respond will have no impact on benefits to which you may be entitled.
1A. DATE OF ISSUE
(mm/dd/yyyy)

1C. DATE OF ISSUE (Month, day, year)

1B. ISSUING OFFICE

1D. VETERAN'S NAME (First, middle initial, last) (This is a mandatory field.)

3. VETERAN'S CLAIM NUMBER

2. NAME OF PHYSICIAN OR FACILITY

4. SOCIAL SECURITY NUMBER

C-

5. AUTHORIZATION VALID
FROM (mm/dd/yyyy)

TO (mm/dd/yyyy)

PART I - SERVICES AUTHORIZED

7. FEE

6. SERVICES SHOWN BELOW AUTHORIZED FOR PERIOD INDICATED IN ITEM 5 ABOVE. (See special provisions on back of form.)

$

8. FEE SCHEDULE OR CONTRACT

9. AUTHORITY

10. ESTIMATED AMOUNT
12. AUTHORIZED BY (Name and Title)

11. FISCAL SYMBOLS
36

0160.001

PART II - INVOICE
14. DESCRIPTION OF SERVICE (If services furnished are identical to those authorized, enter
the remark "As Authorized Above" in this column. Otherwise, itemize services.)

13. DATE(S)
OF SERVICE
MONTH

DAY

15. FEE
CLAIMED
AMOUNT

SERVICE FURNISHED

YEAR

$

15A. SOCIAL SECURITY NO
OR EMPLOYER ID NO

Individual or organization furnishing service, 16. BILLING DATE
enter billing date and amount claimed. (mm/dd/yyyy)
(Continue billing on back if necessary.)

17. TOTAL CLAIMED

$

PART III - FOR VA USE ONLY
AUDIT BLOCK

ADMINISTRATIVE CERTIFICATION
AMOUNT DUE

Payment of this will not cause payee to exceed maximum amount allowed.
Services have been furnished as authorized or medically approved except
as stated below.

DATE

VOUCHER AUDITOR

$
REMARKS

SIGNATURE AND TITLE

ION PAT NO

TC & SC

DATE

PART IV - ACCOUNTING BLOCK

CPF

LIQ

AMT

1ST SA
2ND SA

VA FORM
FEB 2005 (R)

10-7078

$
$

DATE/INITIALS

ORIGINAL

PART II - INVOICE (Continued)
13. DATE(S)
OF SERVICE
MONTH

DAY

15. FEE CLAIMED

14. DESCRIPTION OF SERVICE

AMOUNT

YEAR

$

Please enter total shown in 17A.
Enter this total in 17on front of form also.



16. BILLING DATE



17A. TOTAL
CLAIMED

$

SPECIAL PROVISIONS: Acceptance of this authorization to render service is governed by the following:

*

ACCEPTANCE OF THIS AUTHORIZATION AND PROVIDING OF SUCH TREATMENT OR SERVICES SUBJECTS YOU,
THE PROVIDER OF CARE, TO THE PROVISIONS OF PUBLIC LAW 93-579, THE PRIVACY ACT OF 1974, TO THE EXTENT
OF THE RECORDS PERTAINING THE VA AUTHORIZED TREATMENT OR SERVICES OF THIS VETERAN.

*

Fees or rates listed represent maximum allowance for services specified. In no event should charges be made to the VA in excess of
usual and customary charges to the general public for similar services.

*
*
*
*

Payment by VA is payment in full for authorized services rendered.
Unless otherwise approved by VA, services are limited in type and extent to those shown on the authorization. If services are not
initiated for any reason, return a copy of the authorization to the issuing office with a brief explanation.
A copy of the Operative Report will be forwarded to the authorizing facility within 1 week following any major surgery.
A copy of the hospital summary will be forwarded to the authorizing facility within 10 work days following the release of the patient
from the hospital.

All questions relating to this authorization should be referred to the issuing VA Facility.
VA FORM
FEB 2005 (R)

10-7078

ORIGINAL